DEPARTMENTOFPUBLICSAFETYIP.O.BOX1628ISANTAFE,NM87504-1628
ATTN:RECORDS$15.00PERRECORDCHECK
AUTHORIZATIONFORRELEASEOFINFORMATION
I,,_
___
NAME(MUSTBEPRINTED-LEGIBLY)(SSN#)(DOB)
PURSUANT TONMSA1978,SECTION29-10-6(A) (Repl.Pamp.1990),OFTHE NEWMEXICO ARRESTRECORDINFORMATIONACT,HEREBYAPPOINT:
TRAFFICSAFETYNAME(MUSTBEPRINTED)(IFNOAGENT,PRINT"SELF'')
ADDRESS:
__
AS AN AUTHORIZED AGENT FOR ME FOR THE PURPOSE OF INSPECTING (AND /OR OBTAINING COPIES OF) ANY NEW MEXICO ARREST FINGERPRINTCARD SUPPORTED ARRESTRECORDINFORMATION MAINTAINED BYTHEDEPARTMENTOFPUBLICSAFETY, INCLUDINGINFORMATION CONCERNINGFELONYOR MISDEMEANOR ARRESTSAND INFORMATIONOBTAINED FROMRELEVANTFINGERPRINTDATABASES.
TOTHECUSTODIANOFTHERECORDSINQUESTION,IHEREBYDIRECT YOUTORELEASE SUCHINFORMATION TOTHEAUTHORJZEDAGENTASDESCRJBEDABOVE.
I HEREBYRELEASETHECUSTODIANORCUSTODIANSOFSUCHRECORDSANDTHE DEPARTMENT OFPUBLICSAFETY, INCLUDINGANYOFTHEIRAGENTS, EMPLOYEES,OR REPRESENTATIVES INANYCAPACITY,FROMANYANDALL CLAIMSOFLIABILITYOR DAMAGEOFWHATEVER KINDORNATURE,WHICHATANYTIMECOULD RESULTTOME, MYHEIRS, ASSIGNS, ASSOCIATES,PERSONAL REPRESENTATIVE ORREPRESENTATIVES OFANYNATUREBECAUSE OFCOMPLIANCEBYSAIDCUSTODIAN ORCUSTODIANSWITH THIS"AUTHORJZATIONFORRELEASEOFINFORMATION" ANDMYREQUEST CONTAINED HEREIN FOR THIS RELEASE OR BECAUSE OF ANY USE OF THESE RECORDS. THIS RELEASEISBINDING,NOWANDINTHEFUTURE ANDISVALIDFOR APERJODOFUPTO
120DAYSFROMTHEDATESIGNED,ONMYHEIRS,ASSIGNS,ASSOCIATES,PERSONAL REPRESENTATIVE ORREPRESENTATIVESOFANYNATURE.
APPLICANTSIGNATURE: _
DATE:
_
(*ATTN:NOTARY-ENSURE DOCUMENTISSIGNEDBYBOTHAPPLICANT ANDPARENT (GUARDIAN)INYOURPRESENCEANDNAME,DOB,SOCINFOISVERIFIEDWITHAVALIDID)
SUBSCRIBEDANDSWORN TOBEFOREMETHIS DAYOF_c20__.
(SEAL)ForDepartmentof PublicSafety UseOnly
(NOTARYPUBLIC)
MYCOMMISSIONEXPIRES:------